Primary Prevention Statins in Older Adults: Personalized Care for a Heterogeneous Population
Deirdre O'Neill, MD, MSc; Neil J. Stone, MD; Daniel E. Forman, MD
J Am Geriatr Soc. 2020;68(3):467-473.
The 2018 American College of Cardiology/American Heart Association guidelines on the management of cholesterol acknowledge a lack of robust randomized clinical trial data to support routine use of statin therapy for primary prevention in adults older than 75 years. Shared decision making is emphasized because potential recommendations should reflect limitations of the current data, as well as heterogeneity of the older adult population, spanning the robust to the most frail. Although the National Institute on Aging recently funded PRagmatic EValuation of EvENTs And Benefits of Lipid-Lowering in OldEr Adults (PREVENTABLE), a trial to study benefits of statins in very old adults, data are not anticipated for 5 years. Thus interim guidance is essential. Furthermore, even when PREVENTABLE is completed, individual idiosyncrasies among older adults suggest that decisions for each patient will still need to be personalized, relative to their unique clinical situation. In this article, we present three case studies to highlight dynamics that commonly impact choices regarding statins in older adults. Details underlying shared decision making are also described including the evolving application of coronary artery calcium to inform this practice.